Healthcare Provider Details

I. General information

NPI: 1629734298
Provider Name (Legal Business Name): MONIFA N THELWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 MCDONALD AVE FL 2
BROOKLYN NY
11230-4667
US

IV. Provider business mailing address

405 N LINE ST
LANSDALE PA
19446-2755
US

V. Phone/Fax

Practice location:
  • Phone: 929-491-7333
  • Fax: 215-714-2210
Mailing address:
  • Phone: 305-978-6086
  • Fax: 800-564-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number12567
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN0999269-NP
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP024065
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: